A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Reinforce the importance of daily weights.
Call the health care provider for further instructions.
Document the findings and continue with the visit.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is D
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While parental influence can play a role in substance use disorders, there is no information in the scenario to support this as a potential underlying reason for the client's opioid use.
B. Chronic pain, such as that caused by Crohn's disease and a gymnastics injury, can lead individuals to seek relief through opioid use. Additionally, opioids may be used to selfmedicate underlying anxiety.
C. There is no mention of hallucinations in the client's history, and using opioids to perform better at work is not a typical reason for opioid use disorder.
D. While opioids can induce drowsiness and promote sleep, this is not typically a primary reason for developing an opioid use disorder in individuals with chronic pain conditions.
Correct Answer is A
Explanation
A. A family history of urolithiasis is a risk factor for developing the condition. Genetic factors can influence the risk of developing kidney stones.
B. Diuretic use can increase the risk of kidney stone formation by increasing the concentration of certain substances in the urine that can lead to stone formation.
C. A body mass index (BMI) less than 25 is not typically considered a risk factor for urolithiasis. Obesity, however, can be a risk factor for certain types of kidney stones.
D. Hypocalcemia (low calcium levels) can increase the risk of certain types of kidney stones, particularly those composed of calcium oxalate or calcium phosphate. However, hypocalcemia is not a common risk factor for urolithiasis.
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